Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
FULL TEST BANK
1|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
Test Bank for Medical Surgical Nursing 10th Edition by Lewis
Table of Contents
Section One – Concepts in Nursing Practice
1. Professional Nursing Practice
2. Health Disparities and Culturally Competent Care
3. Health History and Physical Examination
4. Patient and Caregiver Teaching
5. Chronic Illness and Older Adults
6. Stress and Stress Management
7. Sleep and Sleep Disorders
8. Pain
9. Palliative Care at End of Life
10. Substance Use Disorders
Section Two – Pathophysiologic Mechanisms of Disease
11. Inflammation and Wound Healing
12. Genetics and Genomics
13. Altered Immune Responses and Transplantation
14. Infection and Human Immunodeficiency Virus Infection
15. Cancer
16. Fluid, Electrolyte, and Acid-Base Imbalances
Section Three – Perioperative Care
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, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
17. Preoperative Care
18. Intraoperative Care ‘
19. Postoperative Care
Section Four – Problems Related to Altered Sensory Input
20. Assessment of Visual and Auditory Systems
21. Visual and Auditory Problems
22. Assessment of Integumentary System
23. Integumentary Problems
24. Burns
Section Five – Problems of Oxygenation: Ventilation
25. Assessment of Respiratory System
26. Upper Respiratory Problems
27. Lower Respiratory Problems
28. Obstructive Pulmonary Diseases
Section Six – Problems of Oxygenation: Transport
29. Assessment of Hematologic System
30. Hematologic Problems
Section Seven – Problems of Oxygenation: Perfusion
31. Assessment of Cardiovascular System
3|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
32. Hypertension
33. Coronary Artery Disease and Acute Coronary Syndrome
34. Heart Failure 35. Dysrhythmias
36. Inflammatory and Structural Heart Disorders
37. Vascular Disorders
Section Eight – Problems of Ingestion, Digestion, Absorption, and Elimination
38. Assessment of Gastrointestinal System
39. Nutritional Problems
40. Obesity
41. Upper Gastrointestinal Problems
42. Lower Gastrointestinal Problems
43. Liver, Pancreas, and Biliary Tract Problems
Section Nine – Problems of Urinary Function
44. Assessment of Urinary System
45. Renal and Urologic Problems
46. Acute Kidney Injury and Chronic Kidney Disease
Section Ten – Problems Related to Regulatory and Reproductive Mechanisms
47. Assessment of Endocrine System
48. Diabetes Mellitus
49. Endocrine Problems
4|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
50. Assessment of Reproductive System
51. Breast Disorders
52. Sexually Transmitted Infections
53. Female Reproductive and Genital Problems
54. Male Reproductive and Genital Problems
Section Eleven – Problems Related to Movement and Coordination
55. Assessment of Nervous System
56. Acute Intracranial Problems
57. Stroke
58. Chronic Neurologic Problems
59. Dementia and Delirium
60. Spinal Cord and Peripheral Nerve Problems
61. Assessment of Musculoskeletal System
62. Musculoskeletal Trauma and Orthopedic Surgery
63. Musculoskeletal Problems
64. Arthritis and Connective Tissue Diseases
Section Twelve – Nursing Care in Specialized Settings
65. Critical Care
66. Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
67. Acute Respiratory Failure and Acute Respiratory Distress Syndrome
68. Emergency and Disaster Nursing
5|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
6|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
Chapter 1: Professional Nursing Practice Lewis: Medical-
Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the
patient’s input. The patient states, “How is this different from what the doctor does?” Which response would be most
appropriate for the nurse to make?
a. “The role of the nurse is to administer medications and other treatments prescribed by your doctor.”
b. “The nurse’s job is to help the doctor by collecting information and communicating any
problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a
longer time than the doctor.”
d. “In addition to caring for you while you are sick, the nurses will assist you to develop an
individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of nursing, which describes the role of
nurses in promoting health. The other responses describe some of the dependent and collaborative functions of the nursing
role but do not accurately describe the nurse’s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which
statement, if made by the nurse, would be the most accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are evaluated to show that the patient outcomes are consistently met.”
d. “Recommendations are based on research, clinical expertise, and patient preferences.”
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise. Clinical
judgment based on the nurse’s clinical experience is part of EBP, but clinical decision making should also incorporate current
research and research-based guidelines. Evaluation of patient outcomes is important, but interventions should be based on
research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which
statement, if made by the student nurse, indicates that teaching was successful?
a. “The nursing process is a scientific-based method of diagnosing the patient’s health care problems.”
b. “The nursing process is a problem-solving tool used to identify and treat patients’
7|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
health care needs.”
c. “The nursing process is used primarily to explain nursing interventions to other health care
professionals.”
d. “The nursing process is based on nursing theory that incorporates the biopsychosocial
nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of patients’ problems. Diagnosis is
only one phase of the nursing process. The primary use of the nursing process is in patient care, not to establish nursing
theory or explain nursing interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel comfortable leaving my children
with my parents.” Which action should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient’s feelings about the child-care arrangements.
d. Call the patient’s parents to determine whether adequate child care is being provided.
ANS: C
Because a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the
nurse’s first action should be to obtain more information. The other actions may be appropriate, but more assessment is
needed before the best intervention can be chosen.
DIF: Cognitive Level: Apply (application) REF: 6
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which
nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer. The nurse
is able to treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided
weakness is a problem for the patient, the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for
this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired
skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
8|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which
outcome would the nurse recognize as appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the
nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was
resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation phase of
the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patient’s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing
interventions were appropriate. The other responses do not describe the evaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
8. The nurse interviews a patient while completing the health history and physical examination. What is the purpose of the
assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To obtain data with which to diagnose patient problems
d. To help the patient identify realistic outcomes for health problems
ANS: C
During the assessment phase, the nurse gathers information about the patient to diagnose patient problems. The other
responses are examples of the planning, intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
9|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient’s response to a
health problem that can be treated by nursing. The use of a medical diagnosis as an etiology (as in the responses beginning
“Altered tissue perfusion” and “Altered urinary elimination”) is not appropriate. The response beginning “Risk for
impaired tissue integrity” uses the defining characteristic as the etiology.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
10. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include
in the nursing diagnosis statement?
a. The problem and the suggested patient goals or outcomes
b. The problem with possible causes and the planned interventions
c. The problem, its cause, and objective data that support the problem
d. The problem with an etiology and the signs and symptoms of the problem
ANS: D
When writing nursing diagnoses, this format should be used: problem, etiology, and signs and symptoms. The subjective, as
well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the
nursing diagnosis statement.
DIF: Cognitive Level: Remember (knowledge) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced
unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patient’s blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
UAP education includes accurate vital sign measurement. Assessment and patient teaching require registered nurse
education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Apply (application) REF: 11
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:
NCLEX: Safe and Effective Care Environment
12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one
unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if
delegated by the nurse, would be inappropriate?
a. Measurement of a patient’s urine output by UAP
b. Administration of oral medications by LPN/LVN
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit
ANS: C
10 | P a g e
FULL TEST BANK
1|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
Test Bank for Medical Surgical Nursing 10th Edition by Lewis
Table of Contents
Section One – Concepts in Nursing Practice
1. Professional Nursing Practice
2. Health Disparities and Culturally Competent Care
3. Health History and Physical Examination
4. Patient and Caregiver Teaching
5. Chronic Illness and Older Adults
6. Stress and Stress Management
7. Sleep and Sleep Disorders
8. Pain
9. Palliative Care at End of Life
10. Substance Use Disorders
Section Two – Pathophysiologic Mechanisms of Disease
11. Inflammation and Wound Healing
12. Genetics and Genomics
13. Altered Immune Responses and Transplantation
14. Infection and Human Immunodeficiency Virus Infection
15. Cancer
16. Fluid, Electrolyte, and Acid-Base Imbalances
Section Three – Perioperative Care
2|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
17. Preoperative Care
18. Intraoperative Care ‘
19. Postoperative Care
Section Four – Problems Related to Altered Sensory Input
20. Assessment of Visual and Auditory Systems
21. Visual and Auditory Problems
22. Assessment of Integumentary System
23. Integumentary Problems
24. Burns
Section Five – Problems of Oxygenation: Ventilation
25. Assessment of Respiratory System
26. Upper Respiratory Problems
27. Lower Respiratory Problems
28. Obstructive Pulmonary Diseases
Section Six – Problems of Oxygenation: Transport
29. Assessment of Hematologic System
30. Hematologic Problems
Section Seven – Problems of Oxygenation: Perfusion
31. Assessment of Cardiovascular System
3|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
32. Hypertension
33. Coronary Artery Disease and Acute Coronary Syndrome
34. Heart Failure 35. Dysrhythmias
36. Inflammatory and Structural Heart Disorders
37. Vascular Disorders
Section Eight – Problems of Ingestion, Digestion, Absorption, and Elimination
38. Assessment of Gastrointestinal System
39. Nutritional Problems
40. Obesity
41. Upper Gastrointestinal Problems
42. Lower Gastrointestinal Problems
43. Liver, Pancreas, and Biliary Tract Problems
Section Nine – Problems of Urinary Function
44. Assessment of Urinary System
45. Renal and Urologic Problems
46. Acute Kidney Injury and Chronic Kidney Disease
Section Ten – Problems Related to Regulatory and Reproductive Mechanisms
47. Assessment of Endocrine System
48. Diabetes Mellitus
49. Endocrine Problems
4|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
50. Assessment of Reproductive System
51. Breast Disorders
52. Sexually Transmitted Infections
53. Female Reproductive and Genital Problems
54. Male Reproductive and Genital Problems
Section Eleven – Problems Related to Movement and Coordination
55. Assessment of Nervous System
56. Acute Intracranial Problems
57. Stroke
58. Chronic Neurologic Problems
59. Dementia and Delirium
60. Spinal Cord and Peripheral Nerve Problems
61. Assessment of Musculoskeletal System
62. Musculoskeletal Trauma and Orthopedic Surgery
63. Musculoskeletal Problems
64. Arthritis and Connective Tissue Diseases
Section Twelve – Nursing Care in Specialized Settings
65. Critical Care
66. Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
67. Acute Respiratory Failure and Acute Respiratory Distress Syndrome
68. Emergency and Disaster Nursing
5|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
6|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
Chapter 1: Professional Nursing Practice Lewis: Medical-
Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the
patient’s input. The patient states, “How is this different from what the doctor does?” Which response would be most
appropriate for the nurse to make?
a. “The role of the nurse is to administer medications and other treatments prescribed by your doctor.”
b. “The nurse’s job is to help the doctor by collecting information and communicating any
problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a
longer time than the doctor.”
d. “In addition to caring for you while you are sick, the nurses will assist you to develop an
individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of nursing, which describes the role of
nurses in promoting health. The other responses describe some of the dependent and collaborative functions of the nursing
role but do not accurately describe the nurse’s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
2. The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which
statement, if made by the nurse, would be the most accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are evaluated to show that the patient outcomes are consistently met.”
d. “Recommendations are based on research, clinical expertise, and patient preferences.”
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise. Clinical
judgment based on the nurse’s clinical experience is part of EBP, but clinical decision making should also incorporate current
research and research-based guidelines. Evaluation of patient outcomes is important, but interventions should be based on
research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which
statement, if made by the student nurse, indicates that teaching was successful?
a. “The nursing process is a scientific-based method of diagnosing the patient’s health care problems.”
b. “The nursing process is a problem-solving tool used to identify and treat patients’
7|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
health care needs.”
c. “The nursing process is used primarily to explain nursing interventions to other health care
professionals.”
d. “The nursing process is based on nursing theory that incorporates the biopsychosocial
nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of patients’ problems. Diagnosis is
only one phase of the nursing process. The primary use of the nursing process is in patient care, not to establish nursing
theory or explain nursing interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel comfortable leaving my children
with my parents.” Which action should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patient’s feelings about the child-care arrangements.
d. Call the patient’s parents to determine whether adequate child care is being provided.
ANS: C
Because a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the
nurse’s first action should be to obtain more information. The other actions may be appropriate, but more assessment is
needed before the best intervention can be chosen.
DIF: Cognitive Level: Apply (application) REF: 6
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC:
NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which
nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer. The nurse
is able to treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided
weakness is a problem for the patient, the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for
this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired
skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
8|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which
outcome would the nurse recognize as appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid volume that was identified in the
nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was
resolved.
DIF: Cognitive Level: Apply (application) REF: 7
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation phase of
the nursing process?
a. To determine if interventions have been effective in meeting patient outcomes
b. To document the nursing care plan in the progress notes of the medical record
c. To decide whether the patient’s health problems have been completely resolved
d. To establish if the patient agrees that the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired patient outcomes have been met and whether the nursing
interventions were appropriate. The other responses do not describe the evaluation phase.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
8. The nurse interviews a patient while completing the health history and physical examination. What is the purpose of the
assessment phase of the nursing process?
a. To teach interventions that relieve health problems
b. To use patient data to evaluate patient care outcomes
c. To obtain data with which to diagnose patient problems
d. To help the patient identify realistic outcomes for health problems
ANS: C
During the assessment phase, the nurse gathers information about the patient to diagnose patient problems. The other
responses are examples of the planning, intervention, and evaluation phases of the nursing process.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
9. Which nursing diagnosis statement is written correctly?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to response to biopsy test results
d. Altered urinary elimination related to urinary tract infection
9|P a g e
, Test Bank for Medical Surgical Nursing; Assessment and Management of Clinical Problems 10th Edition (Mosby,2016) by Lewis, all 68 Chapters Covered
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patient’s response to a
health problem that can be treated by nursing. The use of a medical diagnosis as an etiology (as in the responses beginning
“Altered tissue perfusion” and “Altered urinary elimination”) is not appropriate. The response beginning “Risk for
impaired tissue integrity” uses the defining characteristic as the etiology.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
10. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include
in the nursing diagnosis statement?
a. The problem and the suggested patient goals or outcomes
b. The problem with possible causes and the planned interventions
c. The problem, its cause, and objective data that support the problem
d. The problem with an etiology and the signs and symptoms of the problem
ANS: D
When writing nursing diagnoses, this format should be used: problem, etiology, and signs and symptoms. The subjective, as
well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the
nursing diagnosis statement.
DIF: Cognitive Level: Remember (knowledge) REF: 7
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced
unlicensed assistive personnel (UAP)?
a. Monitor for shortness of breath or fatigue after ambulation.
b. Instruct the patient about the need to alternate activity and rest.
c. Obtain the patient’s blood pressure and pulse rate after ambulation.
d. Determine whether the patient is ready to increase the activity level.
ANS: C
UAP education includes accurate vital sign measurement. Assessment and patient teaching require registered nurse
education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Apply (application) REF: 11
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC:
NCLEX: Safe and Effective Care Environment
12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one
unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if
delegated by the nurse, would be inappropriate?
a. Measurement of a patient’s urine output by UAP
b. Administration of oral medications by LPN/LVN
c. Check for the presence of bowel sounds and flatulence by UAP
d. Care of a patient with diabetes by RN who usually works on the pediatric unit
ANS: C
10 | P a g e
